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(Circulation. 2003;107:1858.)
© 2003 American Heart Association, Inc.

Clinical Investigation and Reports

What Induces the Warm-Up Ischemia/Angina Phenomenon: Exercise or Myocardial Ischemia?

Peter Bogaty, MD; Paul Poirier, MD, PhD; Luce Boyer, RN; Jean Jobin, PhD; Gilles R. Dagenais, MD

From Quebec Heart Institute/Laval Hospital, Quebec, Canada.

Correspondence to Peter Bogaty, MD, Quebec Heart Institute/Laval Hospital, 2725 Chemin Ste-Foy, Ste-Foy, Quebec, Canada G1V 4G5. E-mail peter.Bogaty{at}med.ulaval.ca

Background— The relation of the warm-up ischemia phenomenon to the presence and intensity of initial myocardial ischemia is unclear. We sought to determine whether the warm-up ischemia phenomenon requires initial myocardial ischemia or can be induced by exercise without ischemia and whether there is a relation between the intensity of initial ischemia and the attenuation of ischemia on reexercise.

Methods and Results— Twelve subjects with exertional myocardial ischemia performed 2 exercise ECG tests (1 and 2) at a ±10-minute interval on 3 occasions (A, B, C) 1 month apart. A1 and A2 were symptom-limited. B1 was kept as long as A1, but its intensity was held under the ischemic threshold (heart ratexsystolic pressure at 1-mm ST depression [STD]) noted at A1. B2 was symptom-limited. C1 was also kept as long as A1 but with an intensity adjusted to maintain one-half maximum STD of A1. C2 was symptom-limited. Exercise duration of A2, B2, and C2 increased similarly compared with A1 (P=0.009). However, the ischemic threshold (x10^-3) increased at A2 (23.5±6.0) compared with A1 (20.3±4.8; P<0.0001) but not at B2 (19.8±5.0) or C2 (21.5±5.8). Similarly, maximum STD adjusted to the highest heart rate–systolic pressure product common to A1, A2, B2, and C2 decreased at A2 (1.4±0.7 mm) compared with A1 (2.5±0.9 mm; P<0.0001) but not at B2 (2.7±0.9 mm) or C2 (2.3±0.9 mm).

Conclusions— Exercises under the ischemic threshold and of intermediate ischemic intensity increase short-term exercise capacity, but myocardial ischemia of more than moderate intensity is needed to induce the warm-up ischemia phenomenon.

Key Words: ischemia • heart diseases • exercise • angina

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